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วันอาทิตย์, พฤษภาคม 23, 2547

TB update15 

@Trop Med Int Health. 2004 May;9(5):559-65.

Direct observation of treatment for tuberculosis: a randomized controlled trial of community health workers versus family members.

Wright J, Walley J, Philip A, Pushpananthan S, Dlamini E, Newell J, Dlamini S.

Bradford Teaching Hospitals NHS Trust, Bradford, UK.

Summary We implemented community-based direct observation of treatment, short course (DOTS), including a randomized controlled trial of direct observation either by community health workers (CHWs) or family members, under operational conditions in a region of Swaziland. There was a high death rate of 15%, due to the high HIV rates in the region. There was no significant difference in the cure and completion rate between direct observation of treatment by CHWs and family members [2% difference (95% CI -3% to 7%), exact P = 0.52]. A before-and-after comparison of outcomes demonstrated that the cure and treatment completion rate improved from a baseline of 27-67% following implementation of community-based DOTS. We conclude that community-based tuberculosis DOTS can improve successful outcomes of treatment. However, direct observation can be undertaken effectively using either daily family or CHW supervision. The choice of treatment supporter should be based on access, patient preference and availability of CHW resource.

=>Community-based directly observed therapy, short course (DOTS) for tuberculosis was studied in a region of Swaziland, along with a study of direct observation either by community health workers (CHWs) or family members. There was a high death rate of 15 percent, attributed to the high HIV rates in the region. There was no significant difference in the cure and completion rate between direct observation of treatment by CHWs and family members. A before-and-after comparison of outcomes demonstrated that the cure and treatment completion rate improved from a baseline of 27-67 percent following implementation of community-based DOTS. Community-based DOTS can boost successful treatment outcome. However, direct observation can be undertaken effectively using either daily family or CHW supervision. The choice of treatment supporter should be based on access, patient preference, and availability of CHW resources

@Lancet Infect Dis. 2004 May;4(5):287-93.
Tuberculosis in New York city: recent lessons and a look ahead.

Paolo WF Jr, Nosanchuk JD.

Department of Medicine, Division of Infectious Diseases, Albert Einstein College of Medicine, Bronx, New York, USA.

In the late 1980s and early 1990s, after decades of decline, the incidence of tuberculosis began to rise in New York city, reaching a peak of 3811 cases by 1992. The epidemic took root in a setting of inadequate treatment regimens, homelessness, a diminished public-health system, and the onset of the HIV/AIDS epidemic. In addition, a subepidemic of drug-resistant tuberculosis occurred throughout New York city, most notably in a series of well documented nosocomial outbreaks. By 1994, using broadened initial treatment regimens, directly observed therapy, and improved US Centers for Disease Control and Prevention guidelines for hospital control and disease prevention, New York city began to effectively halt the progression of the epidemic. By 2002, tuberculosis rates in New York city reached an historic low of 1084. However, given the presence of a large reservoir of latently infected individuals in the city and an ongoing tuberculosis pandemic, New York city continues to face significant challenges from this persistent pathogen.


=> Tuberculosis incidence began to rise in New York City in the late 1980s and early 1990s, reaching a peak of 3,811 cases by 1992. The combination of inadequate treatment regimens, homelessness, a diminished public health system, and the onset of the HIV/AIDS epidemic contributed to the rise. In addition, a subepidemic of multidrug-resistant TB occurred throughout New York City, most notably in a series of well documented nosocomial outbreaks. By 1994, using broadened initial treatment regimens, directly observed therapy, and improved Centers for Disease Control and Prevention guidelines for hospital control and disease prevention, New York City began to halt the progression of the epidemic. By 2002, TB rates in New York City reached an historic low of 1,084. However, given the presence of a large reservoir of latently infected individuals in the city and an ongoing TB pandemic, New York City continues to face significant challenges from this persistent pathogen

@Lancet Infect Dis. 2004 May;4(5):267-77.
Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individual and household level.
Bates I, Fenton C, Gruber J, Lalloo D, Medina Lara A, Squire SB, Theobald S, Thomson R, Tolhurst R.

Liverpool School of Tropical Medicine, Liverpool, UK. ibates@liv.ac.uk

A high burden of malaria, tuberculosis, and HIV infection contributes to national and individual poverty. We have reviewed a broad range of evidence detailing factors at individual, household, and community levels that influence vulnerability to malaria, tuberculosis, and HIV infection and used this evidence to identify strategies that could improve resilience to these diseases. This first part of the review explores the concept of vulnerability to infectious diseases and examines how age, sex, and genetics can influence the biological response to malaria, tuberculosis, and HIV infection. We highlight factors that influence processes such as poverty, livelihoods, gender discrepancies, and knowledge acquisition and provide examples of how approaches to altering these processes may have a simultaneous effect on all three diseases.

@Lancet Infect Dis. 2004 May;4(5):267-77.
Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individual and household level.

Bates I, Fenton C, Gruber J, Lalloo D, Medina Lara A, Squire SB, Theobald S, Thomson R, Tolhurst R.

Liverpool School of Tropical Medicine, Liverpool, UK. ibates@liv.ac.uk

A high burden of malaria, tuberculosis, and HIV infection contributes to national and individual poverty. We have reviewed a broad range of evidence detailing factors at individual, household, and community levels that influence vulnerability to malaria, tuberculosis, and HIV infection and used this evidence to identify strategies that could improve resilience to these diseases. This first part of the review explores the concept of vulnerability to infectious diseases and examines how age, sex, and genetics can influence the biological response to malaria, tuberculosis, and HIV infection. We highlight factors that influence processes such as poverty, livelihoods, gender discrepancies, and knowledge acquisition and provide examples of how approaches to altering these processes may have a simultaneous effect on all three diseases.


@Qual Health Res. 2004 May;14(5):691-703
Pathways to treatment for tuberculosis in bali: patient perspectives.
Watkins RE, Plant AJ.

Division of Health Sciences, Curtin University of Technology, Perth, Australia.

The authors explored treatment-seeking behavior among people with tuberculosis (TB) in Bali, Indonesia. They conducted in-depth interviews with 5 people who had been diagnosed with TB and 6 people who were suspected of having TB but who had not yet received a diagnosis. Participants reported frequent delays in obtaining a diagnosis of TB and obtaining adequate treatment. The authors describe issues associated with treatment-seeking behavior using the following five main themes: awareness of TB-causes, symptoms, and seriousness; influence of others; treatment quality; treatment barriers and default; and stigma and fear. Their findings reinforce the importance of a comprehensive TB control program that provides quality diagnostic and treatment services, and patient and community education, and enables patient involvement in treatment.

@Qual Life Res. 2004 Apr;13(3):639-52.
Quality of life in tuberculosis: patient and provider perspectives.
Hansel NN, Wu AW, Chang B, Diette GB.

Department of Medicine, School of Medicine Johns Hopkins University, Baltimore, MD 21205, USA. nhansel1@mail.jhmi.edu

Tuberculosis (TB) is a persistent problem in the United States; however, little is known about its impact on functioning and quality of life (QOL) among people with TB. The purpose of this study is to describe the impact of TB on patients' QOL by using focus groups to assess the domains of QOL that are affected. Participants included patients (n = 10) who received treatment for active TB and physicians (n = 4) and nurses (n = 9) caring for patients with TB at a public health clinic in Baltimore, Maryland. TB affected all predicted domains of QOL, including general health perceptions, somatic sensation, psychological health, spiritual well-being, and physical, social and role functioning. Social stigmatization, isolation, pill burden, long duration of therapy, sexual dysfunction, loss of income, and fear were additional specific problems related to TB. Surprisingly, 11% (33) of the comments described benefits of TB illness, including increased spirituality and improved life perspectives. In addition, four additional QOL domains and three elements of treatment specific to TB which substantially impact QOL were identified. While patients and clinicians both identified issues in many areas of QOL, only patients mentioned the impact on sexual function, spirituality and improved life perspectives. Despite available curative therapy, TB and its treatment still have significant short and long-term consequences on patients' QOL.

@Qual Life Res. 2004 Apr;13(3):653-65.
Feasibility and reliability of health-related quality of life measurements among tuberculosis patients.

Dion MJ, Tousignant P, Bourbeau J, Menzies D, Schwartzman K.

Respiratory Epidemiology Unit, McGill University, Montreal, Quebec, Canada.

The dramatic global impact of tuberculosis on mortality has been well documented, but its impact on morbidity has not been well described. The emphasis on treatment of latent tuberculosis (TB) infection highlights the tradeoff between short-term decrements in health status from 'preventive' therapy, and long-term gains related to fewer cases of active TB. However, these changes in health status have not been characterized. As a first step, we examined the feasibility and reliability of administering two health status questionnaires, in a multicultural TB clinic setting. The Medical Outcomes Study SF-36 and the EuroQOL EQ-5D were self-administered during 3 weekly interviews. One hundred and eighty-six potentially eligible patients were identified, of whom 112 could be evaluated; 106 (57%) were confirmed eligible. Sixty-seven (63%) agreed to participate; 24 (36%) were women. Fifty-three participants (79%) were foreign-born, with median residence in Canada of 3.5 years. Fifty (75%) of the participants completed all study measurements: 25 were treated for latent TB, 17 for active TB, and eight had previous active TB. Cronbach's alpha coefficients ranged from 0.73 to 0.94 for the SF-36 domain scores. Intraclass correlation coefficients were 0.66 for the SF-36 physical component summary, 0.79 for the mental component summary, and 0.73 for the EQ-5D. These instruments appeared reliable in a highly selected group of TB patients.

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